56 year old male with urinary tract infection

This is an online E-log book to discuss our patients de-identified health data shared after taking his signed informed consent

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patient's with collective current best evidence based inputs.
DEC 2nd,2021

56 YEAR OLD MALE WITH URINARY TRACT INFECTION

CASE DISCUSSION:-

A 56 year old male ,presented to the OPD on 1st December with chief complaints ofChief complaints of
 ->High grade fever since 3 days
 -> Burning micturation since 3 days
 ->Lower back pain since 3 days

HISTORY OF PRESENT ILLNESS:-

 ->4 yrs ago Pt. had fever. Fever was low garde ,associated with chills . 

->Burning micturition since 4 years,which is on and off.Burning is present only during voiding.

 ->4 years ago he was admitted in our hospital and diagnosed with Diabetes mellitus and he underwent dialysis once.

->he is on medication for DM since 2 yrs (H.Actrapid )

-High grade fever with chill since 3 days  associated with burning micturition

- Decreased urine output since 3 days 

- History of vomiting - food as content and billious vomiting since 2 days 

- SOB since 3 days 

- lower back pain since 3 days 

- no complqin of cough , loose stools ,            rashes , body pain , pedal edema 


HISTORY OF PAST ILLNESS :-

- known case of DM since 4 years , on      injection Human ACTRAPID since 2 years 

-was informed to have kidney disease,not on any medication.

- not a known case of HTN , CAD 


PERSONAL HISTORY :-

Diet : Veg 
Appetite : normal 
Bowel movement regular 
Burning micturition 
Occassional alcoholic 
Sleep disturbed 


GENERAL EXAMINATION:-

Patient was examined in well lit room with his consent .
Patient is conscious ,coherent and cooperative 

Patient is well oriented to time and place

Moderately built and nourished

INVESTIGATIONS:-

Pallor:absent

Icterus: absent

Clubbing:absent

Cyanosis:absent

Lymphadenopathy: absent

Edema: absent


VITALS:-

Temperature: 99.3 F

Pulse: 92 / min

Respiratory rate : 25 bpm

Blood pressure : 120/80 mmHg

SpO2 at room air : 98 per cent 

GRBS : 180 mg/dL


SYSTEMIC EXAMINATION :-

Cardiovascular system

-s1 and s2 heard ,no murmurs 

Respiratory system

-Central position of trachea 

-Vesicular breath sounds

-No wheeze,no dyspnea

Abdominal examination

-Scaphoid shape

-No tenderness

-No palpable masses

 -bowel sounds heard 

-No organomegaly

CNS Examination 

-No FND 

PROVISIONAL DIAGNOSIS:-

1)UTI
2)AKI on ?CKD
3) Thrombocytopenia

INVESTIGATIONS:-






On 2/12/2021:-

PH-7.34

PCO2-24.4mmHg

PO2-74.8mmHg

SO2-94.3%

RBS-99mg/dl

HCO3-13.1mEq/L

Dengue-negative

RT-PCR-negative

CUE:-

Pus cells- 3 to 4

Epithelial cells-2 to 3

RBC-nil

FBS-89mg/dl

PLBS-108mg/l

Hb- 14.4 mg/dl

TLC- 7390

PLT- 55,000

BGT- O Positive

Serum Urea- 94

Serum Creatinine- 3.1

Serum Uric Acid- 7.1
Na- 141

K- 4.2

Cl- 102

Total Bilirubin- 4.41

Direct Bilirubin- 2.24

AST- 52

ALT- 22

ALP- 103

TP- 5.5

ALB- 3.3

A/G- 1.61

PT-16

APTT-31


TREATMENT:-

1)IVF- 2NS, 2RS @75ml/hr

2)Inj.Pantop 40 mg IV OD

3)Inj.Zofer 4 mg IV BD

4)syp.Citralka 10 ml in 1 glass of water PO BD

5)GRBS- 6th hourly(8am-2pm-8pm-2am)

6)Inj.Human Antrapid SC TID

7)BP,HR,SPO2 charting

8)Tab.Dolo 650 mg PO TID

9)Inj.Neomol 1 gm IV (if temp >101F)

10) Temperature charting 4th hourly
11)Plenty of oral fuids

12)Strict I/O charting

13)Inj.Ciprofloxacin 200 mg IV BD

14) Syp.Aristrozyme 10 ml PO BD

15)Syp.Sucralfate 10 ml PO BD

Comments

Post a Comment

Popular posts from this blog

MEDICINE BLENDED ASSIGNMENT ( MAY)

May 30,   2021 G.Sahithi Reddy medicine Assignment MEDICINE BLENDED ASSIGNMENT May 24,2021 I have been given the following cases to solve in an attempt to understand the topic of 'patient clinical data analysis 'to develop my competency in reading and comprehending clinical data including history ,clinical findings, investigation and diagnosis and come up with the treatment plan.  This is the link of questions asked regarding the cases: http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1 Below are my answers to the medicine assignment based on my comprehension of the cases Pulmonology https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html Question number-1 1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem? Evolution of symptomology: 20 yrs
Read more

40 YEAR OLD WITH GIDDINESS

Image
  40 year old with chief complaints of  GIDDINESS SINCE 3 DAYS LOOSE STOOLS SINCE 3 DAYS YELLOWISH DISCOLOURATION OF SKIN SINCE 2DAYS HISTORY OF PRESENTING ILLNESS : Patients was apparently asymptomatic back then he developed blebs on skin of the palm and thigh which was itchy and slowly progressed through out all the body over 2 months   No treatment was taken for the same   Lesions are non oozing, initially med which then turned dark and left as pigmented seat on the skin. later 3 days back patient developed loose stools and vomiting after using herbal medications for the lesions Patient skipped 3 days taking insulin   LOOSE STOOLS - water consistency , 20episodes/day , sticky , foul smelling not A/W food intake  VOMITINGS - whitish food , non projectile , not blood tinged  YELLOWISH DISCOLOURATION -  eyes and skin since morning with itching Patient developed ulceration @ Rt foot and had amputation of toe PAST HISTORY    K/c/o Diabetes since 8 years was started initially on OHA’s and
Read more

FINAL PRACTICAL EXAMINATION - SHORT CASE

Image
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  G.Sahithi Reddy Hall ticket no - 1701006043  A 71 year old male patient came to opd with     CHIEF COMPLAINTS OF  Breathlessness and  cough since 20 days HISTORY OF PRESENTING ILLN
Read more